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Provider Questionnaire
Key Medical utilizes the below information to determine which revenue-generating ancillaries are applicable to your practice. Once submitted, a member of our team will contact you within 5 business days.
Facility Name
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Primary Contact First Name
*
Primary Contact Last Name
*
Primary Contact Email
*
Direct Message Address
(May Add Later)
Provider First Name
*
Provider Last Name
*
Provider Title
*
NPI
*
Number of Providers
*
(including Mid-Level)
Number of Locations
*
Facility Website
Number of Active Patients
*
Commercial Percentage
*
Medicare Percentage
*
Medicaid Percentage
*
Managed Medicare Percentage
*
How many patients do you treat per month?
*
Where do you send your patients?
Approximately how many do you refer out per month?
What brand name products do you purchase?
What services of ours are you interested in learning more about?
Who does your billing?